- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,135.26 / $3,135.26 / $3,392.84
| Facility | | $3,135.26 | $3,135.26 | $3,392.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.80 / $80.61 / $90.74
| Professional | | $57.80 | $80.61 | $90.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.03 / $138.03 / $227.75
| Professional | | $138.03 | $138.03 | $227.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $179.95 / $179.95 / $179.95
| Facility | | $179.95 | $179.95 | $179.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.45 / $67.45 / $67.45
| Professional | | $67.45 | $67.45 | $67.45 |